Opinions about Doctors Deceiving Insurance Companies To Obtain Health Services for Their Patients

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The summary below is from the full report titled "Support for Physician Deception of Insurance Companies among a Sample of Philadelphia Residents." It is in the 18 March 2003 issue of Annals of Internal Medicine (volume 138, pages 472-475). The authors are GC Alexander, RM Werner, A Fagerlin, and PA Ubel.

What is the problem and what is known about it so far?

Health insurance companies commonly limit services that patients receive by paying for services only if a patient meets certain requirements. For example, an insurance company may pay for a particular drug only if the patient has tried all less expensive alternatives without success. If an insurance company denies service, the doctor has several options: accept the decision and let the patient go without the service unless the patient pays for it; appeal the decision (a time-consuming option that can involve much paperwork and many phone calls); or tell the insurance company that the patient meets the requirements for the service, even if he or she does not. Several studies have shown that doctors are willing to deceive insurance companies in certain circumstances. However, no published study has looked at how the general public feels about doctors misrepresenting the facts to insurance companies in order to obtain health services for their patients.

Why did the researchers do this particular study?

To determine how the general public feels about doctors deceiving insurance companies to get services for their patients.

Who was studied?

700 people who were waiting to serve jury duty in a Philadelphia courthouse.

How was the study done?

The researchers approached people waiting for jury duty and asked them to complete a short survey in exchange for a candy bar. The survey presented two hypothetical situations in which a doctor might misrepresent the facts to obtain the desired service. The first situation involved a woman with heart disease who the doctor thought needed surgery. The insurance company would pay for surgery only if her symptoms worsened. The second scenario involved a man with back pain who the doctor thought needed a special test to examine the spine. The insurance company would pay for the test only if the patient's symptoms continued or worsened despite further treatment. In each case, the person was asked to say whether the doctor should accept the insurance company's decision, appeal the decision, or misrepresent the facts.

What did the researchers find?

Of the 700 people who completed the survey, 182 said the doctor should misrepresent the facts, 490 said the doctor should appeal the decision, and 28 said the doctor should accept the insurance company's decision. People were most likely to support misrepresentation of the facts if they believed that doctors are too busy to have time for the appeal process.

What were the limitations of the study?

This study included only people in a single, large U.S. city who were waiting for jury duty. The results might not apply to other types of people.

What are the implications of the study?

A substantial number of the people surveyed thought it was acceptable for doctors to misrepresent facts to insurance companies to obtain desired services for their patients.